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Shaw Chiropractic
A Medical-Legal Newsletter for Personal Injury Attorneys
by Dr. Steven W. Shaw

CPT 98: The New Chiropractic Procedure Codes

Every year the American Medical Association updates the Current Procedural Terminology (CPT) manual to reflect the most current procedures and the appropriate coding. The 1998 CPT book has been released and the changes are surprisingly refreshing.

For the first time the AMA has recognized the uniqueness of the chiropractic manipulative treatment and has introduced new procedure codes addressing specifically those treatments. These codes are described as follows: "Chiropractic Manipulative Treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques."

The new codes make for significant changes in the billing procedures used by chiropractors. They also suggest a paradigm shift in the medical perspective of chiropractic physicians and chiropractic approaches. For the past several years chiropractors were required to at least perform a brief evaluation/management (E/M) level of service on every visit. This resulted because the manipulation procedure was considered no more than a physical therapy modality. Therefore, the chiropractor in performing his physician responsibilities was required to evaluate the patient on each visit and make management decisions in addition to providing the manipulation modality. In establishing a new code specifically for chiropractic physicians the AMA has (perhaps inadvertently) recognized chiropractors as specialty physicians. They have now bundled the E/M code and the manipulation and state that "The chiropractic manipulative treatment codes include a pre-manipulation patient assessment."

What does this mean to the attorney who has a client treating with a chiropractic physician? First, you should make sure that the chiropractors billing procedures comply with the current billing practices established by the AMA and HCFA. Second, you can expect the insurance companies to question you with regard to billing changes which begin in 1998 for all physician types (fees and codes). Also, look for carriers to have claims more closely evaluated by outside consulting agencies in an effort to reduce fees below the usual, customary and reasonable levels based upon improper use of the CPT codes

A Comparison of Chiropractic and Physical Therapist Fees

I was shocked the other day when a patient presented me with her statement for the physical therapy that her primary care physician had ordered at one of Connecticut’s largest and most respected physical therapy groups. The patient questioned "Why should I go to them for treatment and pay twice the amount for the same therapy I could get at Shaw Chiropractic?". I had no answer other than that she would have to speak with her primary care physician and tell him what she discovered.

In reviewing the statement from the PT group I noted the following:

1. In a four month period the patient had received 23 PT treatments.

2. The PT visits ranged in price from $160-$230 per visit

3. The total bill was $4140.00 ($180/visit)

4. The individual fees for PT procedures were 20%-60% higher than the same services offered by the Shaw Chiropractic Offices.

5. The respected PT clinic would perform an average of 5 services per visit.

6. The PT notes indicated a miraculous recovery after benefits had been exhausted.

There is a lesson to be learned from this type of billing practice and it’s acceptance in the insurance world. The next time an adjuster suggests that the chiropractic bills were inflated or that the chiropractor over treated you need to compare apples and apples. Point out the facts above. Note that the chiropractor not only treats every visit but evaluates every visit as well (remember the new CMT codes). Let the adjustor know that the same care at a PT clinic would have been more costly and less beneficial. Let them compare line item by line item the services and compare them to regional fee surveys. Point out that the treatment offered seems more than reasonable given the magnitude of the injury or the patients physical findings. Ask them for specific areas which they identify as inflated or over treated and demand to see their protocols or the scientific basis for their conjecture. You will find, as we have, that often times their arguments are without foundation.